Tag Archives: China

The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Elizabeth Hospital (QEH) today (August 31) announced the findings and recommendations of the Investigation Report regarding a sentinel event of a case of barium enema examination:
 
     Arrangements were made for a 79-year-old female patient with chronic illness to undergo a barium enema examination on July 4, at QEH. A radiographer tried to insert the enema tip into the patient’s anus but had improperly inserted it into her vagina. The radiographer did not check the inserting position and received a verbal confirmation from the patient that the enema tip was within her rectum. The radiographer then inflated the retention cuff (or balloon) of the enema to avoid leakage of barium during the examination. After instillation of barium to the catheter, a radiologist found in X-ray images the presence of barium inside the patient’s pelvis, suspecting that the enema tip was improperly inserted into the vagina. The radiologist immediately stopped the examination and asked a radiographer to check the position of the enema tip. The radiographer removed the enema tip after discovering that it was inserted into the vagina. The radiologist immediately examined the patient and found blood stained barium contrast in the patient’s perineum.
 
     Medical staff from Department of Diagnostic Radiology and Imaging immediately escorted the patient to the Accident and Emergency Department. An urgent computed tomography scan was arranged. The result showed that barium existed in her vagina, uterine cavity and bilateral fallopian tubes, and there were also possible signs of vaginal tear. After a joint assessment by a surgeon, gynaecologist and intensivist, an emergency operation was conducted to suture laceration of her vagina, for removal of residual barium and bilateral salpingectomy in order to avoid the risk of peritonitis. The patient was stable after the operation. She made a satisfactory recovery and was discharged on July 24.
 
     Following the incident, the hospital reported the incident to the Hospital Authority (HA) Head Office through the Advance Incident Reporting System. The incident was classified as a sentinel event. QEH has set up a Root Cause Analysis (RCA) Panel to investigate the incident.  After a thorough investigation, the Panel has made the following conclusions:
 

1. During the insertion of the enema tip, the radiographer did not see clearly the patient’s perineum. A visual check was not performed after insertion either. The radiographer should identify the patient’s anus before and immediately after inserting the enema tip to prevent a similar incident from happening again.
2. In this incident, the inflated retention cuff (or balloon) of the enema tip caused injuries to the vagina and forced the barium into the uterine cavity and the fallopian tubes.
3. The incident was a rare one according to the medical literature.

     The Panel has made the following recommendations to QEH and the HA to enhance patient safety:

   1. Review and revise the workflow of the barium enema examination to ensure that:

• After the insertion of the enema tip, another radiographer or a radiologist should reconfirm its position.
• The retention cuff is inflated only after confirmation of the correct position of the enema tip by a doctor. The inflation of the retention cuff should be assessed based on the benefits, risks and needs of individual patients.

    
   2. Share the incident with all staff members of Department of Diagnostic Radiology and Imaging and the lessons learned in formal meetings.

     QEH has explained the investigation results to the patient’s family and delivered an apology again. The hospital will continue to maintain close communication with them and provide the necessary assistance.
 
     The hospital has accepted the Panel’s findings and recommendations, and submitted the investigation report to the HA Head Office. QEH will follow up the case according to prevailing human resources policies. The Department of Diagnostic Radiology and Imaging has formulated and implemented the new guidelines immediately after the incident. After insertion of the enema tip, the radiographer should confirm the correct position of the enema tip with the patient, while another radiographer or radiologist will make a second confirmation before proceeding with the examination.
 
     The hospital expressed its gratitude to the Chairman and members of the RCA Panel. Membership of the Panel is as follows:

Chairman
———-
Dr Danny Cho
Chief of Service, Department of Diagnostic and Interventional Radiology, Kwong Wah Hospital, Tung Wah Group of Hospitals Wong Tai Sin Hospital and Our Lady of Maryknoll Hospital
 
Members
Dr Lo Kit-lin
Chief of Service, Department of Radiology and Organ Imaging, United Christian Hospital
 
Ms Anna Mak
Senior Radiographer, Department of Radiology, Queen Mary Hospital
 
Ms Cora Wong
Nursing Officer, Department of Diagnostic Radiology, Alice Ho Miu Ling Nethersole Hospital / North District Hospital

Mr Apollo Wong
Department Manager, Department of Diagnostic and Interventional Radiology, Kwong Wah Hospital
 
Dr Jackie Chau
Senior Manager (Patient Safety and Risk Management), HA Head Office read more

     The Electrical and Mechanical Services Department (EMSD) today (August 31) made the following response with regard to the investigation report submitted by the MTR Corporation Limited (MTRCL) on its assessment mechanism for the qualification of Engineer’s Person-in-charge (EPIC):
 
     The Government has always accorded top priority to railway safety and has put in place a stringent regulatory system. The EMSD regulates and monitors the safe operation of the railway system according to the Mass Transit Railway Ordinance and its subsidiary regulations, including monitoring the qualifications and training of railway staff. After learning in June this year of the alleged collective cheating in the MTRCL’s EPIC course examinations, the EMSD immediately requested the MTRCL to carry out an investigation into the allegations. The EMSD has in parallel conducted an independent investigation.
 
     The investigation carried out by the EMSD found no evidence that suggested examination leakage or collective cheating by examination candidates, though it does find there is room for improvement concerning the examination system. The EMSD has requested the MTRCL to implement various improvement measures and will closely monitor the MTRCL in implementing these measures in a timely manner, including carrying out random inspections to ensure that the examination system concerned is robust in order to safeguard the safe operation of the railway system. read more

     Following is the transcript of remarks by the Secretary for Transport and Housing, Mr Frank Chan Fan, at a media session after attending the Legislative Council Panel on Transport special meeting today (August 31):

Reporter: But shouldn’t that be something the Government should be well aware of, how the MTRC supervises its projects, instead of not knowing, like with so many unknowns right now? Doesn’t that indicate there is something wrong with the supervision mechanism on the Government’s side, on the Government’s part?

Secretary for Transport and Housing: We are open to all kinds of possibilities, including whether or not and how we would be able to be aware of what’s happening in the past. Basically, we are of the view that there are very likely deception and hiding of facts in the process. This is something not within the system, because all management systems are basically based on trust and of course there are checks and balances. But somehow the system doesn’t work this time and we will look into that, as to how the MTR (Corporation) as well as the Government team should improve in future.

(Please also refer to the Chinese portion of the transcript.) read more

The following is issued on behalf of the Hospital Authority:      The spokesperson for Siu Lam Hospital made the following announcement today (August 31):        Three patients (aged 19 to 58) and a staff member … read more

     The Centre for Health Protection (CHP) of the Department of Health today (August 31) reported the latest number of cases of dengue fever (DF), and again urged the public to maintain strict environmental hygiene, mosquito control and personal protective measures both locally and during travel.
 
     From August 25 to 31 (as of noon), the CHP recorded one imported DF case. The patient had been to multiple countries (Maldives, Malaysia and Japan) during the incubation period. 

     As of noon today (August 31), 90 cases had been confirmed this year, 28 of which were local cases and 62 imported cases. The imported cases were mainly imported from Thailand (26), the Philippines (12) and Cambodia (seven).
 
     DF remains endemic in some areas in Asia and beyond. In Guangdong, there were 121 cases recorded in the first seven months of this year. The latest figures for 2018 reveal that 50 079 cases have been recorded in Thailand, 1 846 in Singapore (since December 31, 2017) and 90 in Japan. In Taiwan, 55 local cases have been recorded to date in 2018. In the Americas, the latest figures indicate that 239 389 and 23 211 cases have been filed in Brazil and Mexico respectively in 2018.
 
     The public should take heed of the following advice on mosquito control:
 

• Thoroughly check all gully traps, roof gutters, surface channels and drains to prevent blockage;
• Scrub and clean drains and surface channels with an alkaline detergent compound at least once a week to remove any deposited mosquito eggs;
• Properly dispose of refuse, such as soft drink cans, empty bottles and boxes, in covered litter containers;
• Completely change the water of flowers and plants at least once a week. The use of saucers should be avoided if possible;
• Level irregular ground surfaces before the rainy season;
• Avoid staying in shrubby areas; and
• Take personal protective measures such as wearing light-coloured long-sleeved clothes and trousers and apply insect repellent containing DEET to clothing or uncovered areas of the body when doing outdoor activities.

 
     To reduce the risk of infections spread by mosquitoes, apart from general measures, travellers returning from affected areas should apply insect repellent for 14 days (DF) or at least 21 days (Zika virus infection) upon arrival in Hong Kong. If feeling unwell, seek medical advice promptly and provide travel details to the doctor. DEET-containing insect repellents are effective and the public should take heed of the tips below:
 

• Read the label instructions carefully first;
• Apply right before entering an area with risk of mosquito bites;
• Apply on exposed skin and clothing;
• Use DEET of up to 30 per cent for pregnant women and up to 10 per cent for children*;
• Apply sunscreen first, then insect repellent; and
• Re-apply only when needed and follow the instructions.

 
* For children who travel to countries or areas where mosquito-borne diseases are endemic or epidemic and where exposure is likely, those aged 2 months or above can use DEET-containing insect repellents with a DEET concentration of up to 30 per cent.

     The public may refer to the CHP’s tips for using insect repellents for details. read more